(BNA) — Legislation intended to improve care for chronically ill Medicare beneficiaries through a potpourri of provisions was approved May 18 in a show of bipartisan support by the Senate Finance Committee.

Some will have a hard time believing that the committee was able to pass “major transformational Medicare reform” in the current political climate, Sen. Ron Wyden (D-Ore.), the committee’s ranking Democrat, said during the markup of S. 870.

But because “more than 90 percent of the Medicare dollar goes toward seniors who have two or more chronic conditions,” members realized the importance of the legislation, Wyden said.

Similarly, Finance Chairman Orrin Hatch (R-Utah) said it was remarkable that the committee passed the bill unanimously despite the “contentious nature of our nation’s current health-care debate.”

There is no immediate schedule to bring the measure to the Senate floor as a solo bill, committee aides told Bloomberg BNA. They said initial contacts have been made with House committees and that some of the provisions in S. 870 have been included in individual House bills.

Spending

The legislation would be paid for between 2018-2022 mostly through $370 million from the Medicare Improvement Fund, which is intended to make improvements for beneficiaries, according to a preliminary committee estimate from the Congressional Budget Office. Another $5 million would come from the Medicaid Improvement Fund.

The bill would cut direct spending by $217 million during that period, the estimate said.

The bill, a product of a committee working group, takes a broad approach to tackling high spending for chronic conditions. Changes are spread across fee-for-service Medicare, Medicare Advantage, and accountable care organizations.The provisions include extending and expanding an Affordable Care Act home care program, called Independence at Home, and would allow beneficiaries receiving home dialysis to get assessments through telehealth services.

MA Changes

It would permanently reauthorize MA special needs plans if certain policy requirements are met. The three types of SNPs are aimed at beneficiaries dually eligible for Medicare and Medicaid, those with chronic conditions, and those who are institutionalized.

Additionally, MA plans would be allowed to offer supplemental benefits to meet the needs of chronically ill enrollees.

The bill would expand the ability of MA plans and some ACOs to use telehealth services. ACOs would also have expanded ability to enroll beneficiaries through prospective assignment.

Amendments

The committee approved an amendment that would allow Part D drug plan sponsors to obtain claims data under Medicare Parts A and B. The data could be used to optimize health-care outcomes through better medication use and improved care coordination.

Other amendments, including one by Sen. Benjamin Cardin (D-Md.) that would have repealed the therapy cap requirement, were put aside. The controversial caps impose a limit for beneficiaries on physical therapy, speech-language pathology, and occupational therapy. Congress has repeatedly extended an exception process that allows beneficiaries to receive an unlimited amount of rehabilitation services if medically necessary.

Health Plan Support

Health plan groups issued statements lauding the bill’s passage.

The Alliance of Community Health Plans said it was particularly supportive of the enhanced telehealth services and provisions on MA plans.

The National Association of ACOs said it appreciated “greater flexibility” accorded ACOs.

The Association for Community Affiliated Plans said permanently authorizing SNPs would help to lessen uncertainty by states that want to invest in integrated models for dual eligibles.

The Senate Finance Committee on Thursday (May 18) unanimously passed bipartisan Medicare chronic care legislation that is the culmination of years of work on the issue, though lawmakers suggested the committee still needs to focus on some issues including ways to make the Independence at Home demonstration permanent. The bill as passed included a few tweaks, including new language giving practices more time to show savings through the Independence at Home demonstration, changing the definition of conditions a beneficiary can have to participate in a chronic condition special needs plan, and requiring additional studies from the Government Accountability Office and the Medicare actuary.

The bill includes a two-year extension of the Independence at Home demonstration, and changes in the chairman’s mark make it easier for practices to participate in the demonstration by giving them three years to demonstrate savings without a requirement that the practice also receives an incentive payment, rather than two as required by current law, according to a summary of tweaks to the legislation. As passed, the chairman’s mark also adds a requirement that the evaluation of the demonstration look at participating practices’ use of electronic health information systems, including remote monitoring, to the extent that information is available.

Sen. Rob Portman (R-OH) lamented the fact that the demonstration could not be made permanent, and blamed that on the Congressional Budget Office’s score.

“I wanted it to be permanent,” Portman said, adding that the committee settled on a two-year extension because of CBO — though he thinks the CBO score for making the demonstration permanent is misleading. Portman expressed hope that having the program in place for another two years will bring in data showing the initiative saves money. “My hope is we can get CBO to recognize the cost savings that come from this home-based program and this data will be helpful,” Portman said.

Finance Committee ranking Democrat Ron Wyden (OR) said he shares Portman’s views that lawmakers need to relentlessly focus on making the demonstration permanent, and said the program is on the “right side of history.”

The chairman’s mark also tweaked the definition of a chronic condition that would allow a beneficiary to participate in a C-SNP. The bill, as passed by the committee, calls for the C-SNP condition clinical advisory panel to include as conditions that make a beneficiary eligible to participate in a C-SNP those that require prescription drugs, providers and models of care that are “unique to a specific population of enrollees of a C-SNP” and where a C-SNP could help slow or halt the progression of a disease, improve outcomes or decrease beneficiary costs compared to other options. A condition that would allow for C-SNP participation could also be shared by those participating in the plan but uncommon in the general Medicare population, or one with a disproportionately high per-beneficiary cost.

The chairman’s mark also would modify the feedback HHS solicits on what telehealth procedures should be available through Medicare Advantage, and says MA plans must provide access to those services in person, as well, so that beneficiaries have a choice of how to receive their care.

The chairman’s mark also includes an amendment submitted by Sens. Bob Casey (D-PA) and Portman calling for HHS to consider the impact of looking at SNPs’ quality data reporting at a plan level on those that serve a disproportionate number of dually eligible beneficiaries.

The bill also calls for a GAO study, part of an amendment submitted by Sen. Maria Cantwell (D-WA), on state Medicaid programs’ work to rebalance duals’ long-term care from institutions to home and community-based settings, and the effect of those efforts on Medicare spending.

Also included in the chairman’s mark is an amendment by Sens. Tom Carper (D-DE) and Bill Cassidy (R-LA) requiring the Medicare actuary study long-term risk factors for the prevalence of chronic conditions in the Medicare population.

The committee also passed an amendment from Carper and Sen. Pat Roberts (R-KS) that would allow Part D plans to request Medicare Parts A and B claims data.

Lawmakers at the committee’s Tuesday (May 16) hearing on the bill praised its bipartisan nature, and many at the markup Thursday reiterated that praise. Wyden again touted the committee’s ability to pass what he called a major Medicare bill in this partisan environment. Committee Chair Orrin Hatch (R-UT) commended his colleagues, particularly Wyden and Sens. Mark Warner (D-VA) and Johnny Isakson (R-GA) who led the working group on the issue. However, he cautioned that “now is not the time to celebrate anything. We’ve got work to do.”

Congress is taking a small, but important, step towards expanding Medicare to include some long-term supports and services. A bipartisan (yes, bipartisan) measure before the Senate Finance Committee would give some Medicare providers additional flexibility in the way they care for people with chronic conditions, who are among the program’s highest need and highest cost beneficiaries.

Given the current political environment, Congress would take a major step by even acknowledging that people with chronic conditions may require services that Medicare does not now offer. The sponsors of the bill include Finance Committee Chair Orrin Hatch (R-UT) and top committee Democrat Ron Wyden (D-OR) as well as Johnny Isakson (R-GA) and John Warner (D-VA). The Finance panel held a hearing this on the bill yesterday and plans to vote next week to send the measure to the full Senate.

Expanding Managed Care

CHRONIC would expand the use of telehealth, extend and expand a home-based medical practice experiment called Independence at Home, and improve the Medicare appeals process for people in risk-based insurance plans such as Special Needs Plans (SNPs). But the biggest changes would apply to the care provided by managed care programs.

One would expand the use of those special needs plans, which are explicitly aimed at people with chronic conditions and high medical needs. Some of these programs already provide supports and services as part of their benefit packages but they remain relatively small.

The other would give Medicare Advantage plans important new flexibility to offer social supports and other non-medical services to their members. About one-third of Medicare enrollees are in MA plans.

Paying for Meals and Rides

Today, these managed care plans must provide identical benefits to all their members regardless of health status, and services are limited to those that are “primarily health-related.” That means that fitness benefits are OK, but home-delivered meals or medical transportation are not. For many older adults with chronic conditions, a ride to the doctor or a hot meal to stave off malnutrition are crucial to their well-being. And such services may reduce the chances of emergency room visits or hospitalizations.

CHRONIC would change those rules. It would allow MA plans to target specific supplemental benefits to their high-need members with chronic conditions. And, according to a summary of the bill, it would permit benefits that “have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee and would not be limited to primarily health-related services.’

That doesn’t exactly say long-term supports and services, but it comes awfully close.

A Potential For Savings

The Bipartisan Policy Center, which has recommended many of the changes that found their way into CHRONIC, estimates that for an additional $5 per month, MA plans could provide a member with in-home meal delivery, non-emergency medical transportation, minor home modifications, and targeted case management services. In testimony to the Finance panel yesterday, BPC’s director of health policy, Katherine Hayes, put it cautiously but accurately: “If the provision of these non-Medicare-covered social supports reduced hospitalizations, emergency department visits, and other Medicare spending for the targeted group of enrollees, there is also a potential for savings.”

One example of how these programs can help those with chronic conditions is CAPABLE, a demonstration created by Sarah Szanton and her colleagues at Johns Hopkins. The program is built around a team that includes an occupational therapist, a nurse, and a handyman. They first determine a patient’s goals and then provide modest home repairs and modifications as well as assistive devices as needed. The results: Three-quarters of participants improved their ability to do activities such as walking, dressing, or bathing. However, the CAPABLE experiment was available only for those who are dually eligible for Medicare and Medicaid, not for the Medicare-only population.

We are learning that programs such as this can work. And they very likely can help those who receive only Medicare. Now, a bipartisan group of senators is taking some initial steps to open the door to those services.

AHA News Now – The Senate Finance Committee today voted unanimously to approve the CHRONIC Care Act (S. 870), legislation to improve care management, coordination and outcomes for Medicare beneficiaries with chronic conditions. Among other provisions, the bill would extend the Independence at Home demonstration; provide certain flexibilities for Medicare Advantage plans; give MA plans and certain accountable care organizations greater flexibility to offer additional telehealth services; and expand access to telehealth for home dialysis and stroke assessments. The bill would not reimburse hospitals where the patient is present a separate, originating site fee. In comments submitted to the committee last year, AHA voiced support for a number of the bill’s provisions, but continues to advocate for more comprehensive Medicare coverage and payment policies for telehealth services, especially for hospitals that serve vulnerable rural and urban communities.

Cost Savings and Improved Quality of Care are Hallmarks of Medicare Demonstration Project

Newswise — Washington, D.C. – The American Academy of Home Care Medicine (AAHCM) applauds the Senate Finance Committee for passage of legislation, this week, that includes extension and expansion of the Independence at Home (IAH) demonstration through the CHRONIC Care Act of 2017. The IAH provisions of the bill extend the program for an additional two years past its September 2017 expiration, increase the cap on the total number of participating beneficiaries from 10,000 to 15,000, and improve the ability of IAH programs to best serve their patients.

AAHCM is a leading advocate for the IAH model which uses interdisciplinary teams of medical and social services professionals to provide care to elders with severe chronic illness and disability in their homes, providing high quality clinical care and excellent patient experience while promising to significantly lower costs for the Medicare program.

AAHCM president Mindy Fain, M.D. said, “We especially appreciate statements made by long-time IAH champions Senator Rob Portman (R-OH) and Ranking Member Wyden (D-OR) during the bipartisan, unanimous vote in the Finance committee hearing.” She added, “Both Senators not only praised the IAH program for its quality of care and cost savings, but also promised to continue their work to transform IAH into a national program.”

Senator Portman said, “I have seen the benefits the IAH program has provided for seniors in Northeast Ohio—it has reduced hospital readmissions, prevented costly hospital and nursing home admissions, and, most importantly, kept patients healthy and in their preferred care setting.” He pledged, to “continue to fight to make the Independence at Home program permanent.” Ranking Member Wyden replied, “I very much share your view that we have to relentlessly focus on getting IAH made permanent because it is in the right side of history – giving older people more of what they want which is to be at home with a real opportunity to save dollars.”

The Centers for Medicare and Medicaid Services (CMS) found that IAH practices saved over $35 million during the first two performance years while delivering high quality patient care in the home.

Legislation to make the IAH demonstration nationwide, The IAH Act (S. 464), was introduced this February by Senators Ed Markey (MA), John Cornyn (TX), Michael Bennet (CO), and Rob Portman (OH). The bipartisan legislation would expand the IAH demonstration to reach as many as 1.5 million elders with severe chronic illness and disability.

AAHCM is a non-profit professional association that represents physicians, nurse practitioners, physician assistants, social workers and others working in the field of home care medicine. AAHCM conducts educational conferences to advance interdisciplinary, high value health care in the home for all people in need, fosters professional development and advocates for health policy issues that advance the practice of home care medicine. For more information, visit https://www.aahcm.org.

A bill to improve care for Medicare beneficiaries with chronic conditions advanced in the Senate, while the FDA issued a boxed warning on an increased risk of foot and leg amputations for some type 2 diabetes drugs.

The Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 would increase access to telehealth for Medicare beneficiaries with chronic illnesses — including those in Medicare Advantage plans — as well as provide more incentives for enrollees to receive care through accountable care organizations (ACOs). It also would extend the Independence at Home demonstration program to keep people in their homes rather than hospitals, allow reimbursement for more non-health and social services, and extend permanently MA Special Needs plans that target chronically ill beneficiaries.

“One thing we hear a lot from ACOs is they have trouble keeping beneficiaries in-house rather than going to a provider outside the ACO, and that makes it harder to coordinate their care,” a committee aide said. “This bill says that if you go to a primary care doctor in the ACO, we’ll reduce or eliminate your cost-sharing for that primary care service. That will make beneficiaries stick to the ACO, and bring down their costs.”

Media reports Friday indicated that when the Congressional Budget Office finally scores the American Health Care Act, the repeal-and-replace bill passed by the House in a close vote, it may need to be modified and voted on again.

“The CBO score will … determine whether the bill meets Senate requirements,” The Hill explained. If the review finds that the legislation would expand the federal deficit, then it can’t be passed under the so-called reconciliation process. Republicans have hoped to use that process to short-circuit an expected Democratic filibuster in the Senate. Consequently, an unfavorable review may impel GOP House leaders to amend the bill once again and submit it for another floor vote.

The warning comes after the agency reviewed data from two randomized, placebo controlled trials (CANVAS and CANVAS-R) that showed rates of lower-extremity amputations were doubled in the active drug groups, irrespective of dose.

Among nearly 6,000 patients receiving canagliflozin in the two trials, rates of amputations were 5.9 and 7.5 per 1,000 patient-years, compared with 2.8 and 4.2 per 1,000 patient-years in the placebo groups. The differences were statistically significant.

Under the proposed changes, which would affect SHOP enrollees who use health insurance exchanges facilitated by the federal government, “Online enrollment would be removed from HealthCare.gov and small employers would access coverage through an agent or broker, or an issuer of their choice, for plan years beginning on or after January 1, 2018,” the Centers for Medicare & Medicaid Services (CMS) said in a press release.

Employers would still use the healthcare.gov online portal to get qualified to participate in SHOP, and small businesses with a SHOP plan for the 2017 plan year could still use the online portal for enrollment and premium payment until their plan year ends, the release noted.

“Our goal is to reduce ACA burdens on consumers and small businesses and make it easier for them to purchase coverage,” said CMS Administrator Seema Verma in the release. “The ACA has failed to provide affordable insurance to small business and to the American people. This new direction will help employers find affordable healthcare coverage for their employees and make the SHOP exchanges function more effectively.”

House appropriations subcommittee chairman Tom Cole (R-Okla.) said he was “especially disappointed” that President Trump’s proposed budget included an $8 billion cut for NIH. “That would potentially discourage promising scientists from entering or remaining in biomedical research,” he said.

“Everyone on this committee recognizes the importance of restoring the purchasing power of NIH,” said Rep. Rosa DeLauro (D-Conn.) the subcommittee’s ranking member, who noted that as an ovarian cancer survivor, the NIH’s mission was of great personal interest to her. The proposed cut “would decimate NIH and reduce the agency’s research purchasing power to levels not seen since the 1990s … When we face a public health emergency, NIH research is often our best tool to combat the tragic loss of life.”

Independence at Home program brings primary care medical services to Medicare beneficiaries with multiple chronic conditions in their homes; has saved more than $30 million in first two years

Washington (May 18, 2017) – Today, Senators Edward J. Markey (D-Mass.) and Ron Wyden (D-Ore.) applauded Senate Finance Committee passage of a comprehensive chronic care package that included a two-year extension and expansion of the Independence At Home (IAH) Program, an innovative home-based primary care program that brings measurable, high-quality care to patients suffering from multiple debilitating diseases while significantly lowering costs for the Medicare program. The IAH program empowers teams of doctors, care givers and other health care professionals to coordinate and provide primary care services in the comfort of patients’ own homes, reducing unnecessary emergency room visits and avoidable hospitalizations and readmissions, as well as the costs associated with them. This is an important step to expanding this program nationwide so that all older Americans, regardless of where they live, can have the opportunity to receive the best care in the most appropriate setting for their needs. The CHRONIC Care package must now be voted on by the full Senate.

“Independence at Home is putting health care in the living room instead of the emergency rooms and the Medicare program is seeing the benefits,” said Senator Markey. “We are improving the care that patients suffering from diseases such as Parkinson’s and Alzheimer’s receive and saving taxpayers money by catching emerging health problems early. I thank Senator Wyden for his years of partnership on this program that is improving the lives of Medicare beneficiaries and their families.”

“I’m proud that the Finance Committee’s CHRONIC Care Act included the extension and expansion of a key priority of mine – the Independence at Home program,” said Senator Wyden. “Independence at Home represents the idea that Medicare can provide high-quality care to seniors with complex chronic conditions where they want it most – at home. Oregon has a long tradition of this kind of care, particularly through Housecall Providers which has been a leader every step of the way, and I’m thrilled that they will continue to be rewarded for the transformational work they are doing.”

In 2012, Independence At Home began as a three-year demonstration program. In 2015, the House of Representatives and Senate approved a two-year extension. Senators Markey and Wyden are the original co-authors of the Independence at Home program.

Measures Passed as Part of Bipartisan Bill to Strengthen Focus on Chronic Care Services for Seniors

WASHINGTON, D.C. (May 18, 2017) – U.S. Senator Rob Portman (R-OH) today announced that several key health care priorities he has authored have passed the Senate Finance Committee as part of the Chronic Care Act and are now ready for action on the Senate floor.

“I am pleased the Finance Committee, through today’s passage of the CHRONIC Care Act, has begun a bipartisan process to strengthen our health care system by enacting policies that promote prevention and empower patients by providing them with tools they need to better manage their health care,” said Portman. “The bill includes a number of policies that will promote increased care coordination and help patients and providers better manage chronic conditions. The bill also includes a number of priorities I have worked on, including ensuring that Medicare beneficiaries can receive high-quality, personalized care at home, incentivizing beneficiaries to receive preventive services and better manage their health care, and ensuring the Medicare Advantage program includes accurate quality measures to incentive plans to continue to care for low-income seniors.”

Following is more specifics on key Portman priorities passed as part of the Chronic Care Act:

Independence at Home Act (IAH) Extension. This bill would extend the IAH demonstration’s expiration date by two years (until September 30, 2019), increase the cap on the total number of participating beneficiaries from 10,000 to 15,000, and give practices three years to receive a shared savings payment.

“I have seen the benefits the Independence at Home program has provided for seniors in Northeast Ohio—it has reduced hospital readmissions, prevented costly hospital and nursing home admissions, and, most importantly, kept patients healthy and in their preferred care setting,” said Portman. “I am pleased the committee included a two-year extension of this program in the CHRONIC Care Act to ensure beneficiaries in Ohio and across the country can continue to receive high-quality care in their preferred setting—at home. I will continue to fight to make the Independence at Home program permanent.”

Better Health Rewards Program in the Accountable Care Organization (ACO) Setting. The CHRONIC Care Act includes a new program called the ACO Beneficiary Incentive Program, which wouldallow ACOs to make incentive payments to their members who seek out preventive care or chronic disease management services.

“I am particularly pleased the committee has included a policy that draws on the idea of the Better Health Rewards bill I have worked on with Senator Wyden. This program will allow Medicare to engage seniors in their healthcare—incentivizing seniors to set goals and meet health targets,” said Portman. “We should continue to promote programs that allow seniors the option to participate in programs that allow them to take control over their health care – enabling them to live better, healthier lives while also saving the Medicare system money without making cuts to benefits.”

Ensuring Medicare Advantage Quality Measures Account for the Most Vulnerable Population. The bill includes a provision that builds on Portman’s work with Senator Casey to ensure the most vulnerable Medicare beneficiaries—including low-income, disabled, and dually-eligible seniors—are able to maintain access to high-quality Medicare Advantage plans.

“Today’s passage of the CHRONIC Care Act is an important step forward for people suffering from debilitating diseases in Colorado and across the country,” Bennet said. “Chronic conditions strain families and increase health care costs. By modernizing the Medicare program, we can address both of these challenges. We’ll work to advance this bill, so we can improve the health and well-being of families, reduce costs, and improve patient outcomes.”

Bennet and other members of the Finance Committee introduced the CHRONIC Care Act last month. The legislation includes a provision to expand the Independence at Home (IAH) program, based on a bill Bennet introduced with Senators Markey, Portman, and Cornyn earlier this year.

The Senate Finance Committee today approved the legislation unanimously by a vote of 26-0.

“It’s common sense that Medicare policies should help prevent a heart attack or stroke instead of treat the heart attack or stroke after they occur,” Grassley said. “That means coordinating care among the doctors treating patients with diabetes, obesity or high blood pressure to prevent serious complications. It means improving telehealth so residents of rural Iowa can get help right after a stroke when there’s no neurologist in the area. It means better management of medications to prevent over-medicating or harmful interactions. These steps and more mean people can stay healthier and in their own homes, where they want to be, instead of hospitals or nursing homes. The bill accomplishes all of this without spending more money.”

The Finance Committee unanimously passed the CHRONIC CARE Act. The measure was developed through the committee, where Grassley is a senior member and former chairman, and includes several of Grassley’s legislative priorities

It extends the Independence at Home demonstration project, which allows at-home care for Medicare beneficiaries with multiple chronic illnesses. This can keep people out of nursing homes, a long-time Grassley goal.

The bill allows beneficiaries receiving kidney dialysis at home to do a required monthly check-in with their doctor via telehealth rather than having to go to the doctor’s office or hospital. “This is helpful for at-home dialysis patients in rural areas,” Grassley said.

It expands the use of telehealth services to Medicare Advantage enrollees. The measure expands the use of telehealth for individuals experiencing a stroke. Telestroke programs provide for rapid diagnosis and treatment to prevent death and disability in rural areas where there are no neurologists available. For example, several regional hospitals are connected to stroke specialists at the University of Iowa Hospitals and Clinics for fast consultation via video and data connection. Grassley is a cosponsor of S. 431, the Furthering Access to Stroke Telemedicine Act (FAST Act), which would also accomplish this goal.

The CHRONIC CARE Act requires multiple studies, including reports on improving medication synchronization and the impact of obesity drugs on patient health and spending. Grassley is an original co-sponsor of S. 830, the Treat and Reduce Obesity Act of 2017. This legislation would give Medicare beneficiaries and their health care providers additional tools to reduce obesity by improving access to weight-loss counseling and new prescription drugs for chronic weight management.

The measure includes provisions to further move Medicare Advantage toward payment for quality of care. Grassley works to make sure Medicare payment policies reward quality, not simply pay for services.